good morning everybody and thank you for being so numerous to this meeting a meeting the wing which we shall try to focus on the main topic of a festival dedicated to unequal health health focusing on obesity and equal health is a very interesting topic because it puts together different competencies and different situations so health has been brought to the festival of economics we have lawrence coyer here a physician also teaches at the pennsylvania university and an economist doctors kiersten stromboton who after obtaining her phd in yale in health policy and management is now working at the american institute of research in washington dc i am a physician i have a university degree in medicine but i've always been working as a journalist and never in my life would i have thought to come to a festival of economics especially on this side of the desk anyway this is a sign of our time we have finally understood that to tackle complex problems that we have to get together to unite our forces to merge our competencies so that we can approach problems from different viewpoints i invite you all to come at six o'clock at that resetale to listen to michael marmot who back in 2004 gave the following definition status syndrome this means that there is a syndrome which is related to the social status to the economic status it is obviously clear that if you are very poor you do not enjoy such a good health as those who can actually be taken care of and cured in the best possible way however the issue is much more complex and less direct than we could think obesity in particular is a theme where we can actually take many aspects into consideration genetics personal behavior or lifestyle and this is what we're going to focus on today because obesity certainly partially depends on how much and what we eat but it also depends on environmental factors i like to quote the following example i live in milan and recently the porta nuova area in milan has been refurbished and restructured with the beautiful girl in this square and many beautiful cycle puffs so today instead of taking the car or the underground we like to walk to cycle my child goes to school by bicycle well these decisions have a significant impact on health and as far as the visit is concerned we tend to say that the larger your flat the smaller your size well this actually reflects our culture and our situation a visit is more frequent in the lower social classes and economic classes compared to the higher ones where more attention is paid to what you eat people do more exercise they go to the gym totally upsetting a historical relationship because in the past people who had access to more food actually were fatter and this coincided with the higher social economic classes conversely people starved and died of deprivation so things have changed completely and what can we do to reduce the disequality the social economic disequality that has such a strong impact on health as well well i would like to ask our kirsten sterner to give us her presentation that will try to explain exactly this good morning i hope i'll speak slow enough that the translator can keep up with me just to give you some background i'm a health economist i do research on the economics of obesity specifically obesity policy so thinking about the ways that we can address the consequences of the way we eat and what i want to do today is kind of frame our panel discussion more broadly and and think about first what do economists even have to say about our health and our eating habits and i think we have much to contribute towards both measuring the economic consequences of what we eat and understanding the um the economic and market factors that contribute to obesity ultimately our health and i always approach it from the obesity perspective but health more broadly is the result of a series of dynamic decisions about our health behaviors which kind of the perfect topic for economists to dig into and i think it provides a really important and useful framework for thinking about the appropriate role for government intervention so as i move through this talk i kind of want to have a few questions in our heads some some big picture questions and the first is is there a rationale for government intervention right we can answer this question or try to answer it from a neoclassical perspective so from the traditional chicago school of thought second is should the government save people from themselves so beyond the neoclassical arguments for intervention what's the appropriate role for government in this instance and then how what what's the most appropriate and effective way to do this so let me let me start off the talk by showing you these are the top 10 leading causes of death in the u.s and i'll show i'll show you the italian version of these rankings as well but the spoiler alert is that they're quite similar and what you'll notice from these top 10 causes of mortality is that they're directly related to health behaviors heart disease lung disease diabetes going beyond this most of them can be correlated or show positive associations with our diet or what we eat this is the same for italy these are the top 10 leading causes of mortality in your country again directly related to health behaviors per se and many correlated with diet so i'll talk about the evidence in a second for what that means to be correlated with diet but when we talk about the ways in which what we eat and being obese is associated with our health and the health consequences of being obese it really affects the entire body i mean from heart disease associations with cancer gout diabetes arthritis pretty much everything has a link to being obese and ultimately what we eat i like to ground our talk and kind of thinking about the magnitude of this problem so the arrow points to italy you guys actually you've got relatively good obesity rates for adults in your country about one in ten italian adults are obese that's compared to one in six for the oecd average and one in three for the american population so this this panel talk is ultimately about whether what we eat is to blame for our health and what impact it has on longevity and professor steckler couldn't make it so i'm going to try and take on a little bit of his talk and just kind of give you a flavor of why that question is so difficult to answer so is there a link between diet and health the short answer is yes the long answer is yes but there's very little consensus beyond that simple statement nutrition at least in my country talking about nutrition is a little bit like talking about religion everyone has their beliefs about what's healthy we come with our priors and part of that is because we all feel like experts we all eat every single day multiple times a day and if i have a glass of wine and i feel great i'm ready to tell my family and my friends that they should also have a glass of wine and convert them to my ways and ignore all other research and this is kind of one of the big pitfalls of science and this is any science not just nutrition or economics is that once you think you understand something kind of ignore all hypotheses to the contrary and when we talk about nutrition research specifically it's inherently difficult just the nature of it is very very difficult that's because our gold standard for looking for evidence randomized controlled trials are really difficult to do in human beings it's because they're expensive they're expensive to do in the long term which is when we might expect to see outcomes in our health related to our diet and humans are valuable it's very it's you know larry can tell you it's very difficult to get humans to adhere to any particular set of diets you can maybe do it for a week and people will stick to a low fat or a low carb but after a couple weeks they start to trend back to where they started out so even when you can pay for the randomized control trial it's very difficult to get people to adhere to it so in the absence of randomized controlled trials what do we do for nutrition research well we rely on observational studies which are also oftentimes flawed not by any fault of the researcher but by lack of data they tend to be many of them tend to be correlational so i don't know if you were at the introductory section to the the conference yesterday but there was a comment about parents who read to children also find that their children have better health so we should all read to our children and while that's a very um you know it's a great idea it's not necessarily implied from the research study that it's a causal relationship so you'll see this all the time if you read a magazine or a newspaper a really sexy headline about you know coffee so people who drink coffee live longer so drink coffee or live longer and that data usually comes from a study where we look at individuals who drink coffee and we look at how long they live and we see they live longer and we make an assumption drinking coffee makes you live longer but actually what could be going on is that people who drink coffee are more educated their academics their writers their doctors they make a lot of money and what could really be driving longevity is the higher education and the income that gives you access to more research resources so it's not the coffee per se that's causing the outcome it's all of these other unobserved factors so this is a very broad problem when we do nutrition research in addition it's usually based on self-reported measures so we call up people and we say how many glasses of wine or um how much sugar did you have last week and we asked people to tell us and you know we'll get some kind of estimate maybe they're too embarrassed to tell us the truth maybe they don't remember but ultimately those are the measures that we're using to make inferences about health so this is this is not great for nutrition research in general but it can actually be quite dangerous when we go to make policy recommendations from non-causal or flawed estimates so this is a graph of the seven countries study by ansel keys was done in 1953 and what it shows is a relationship a positive relationship between saturated fat intake and your health mortality and what happened was we kind of ran with that in the u.s and we thought nutritionists got very excited about this research and they said fat must be bad for you and this whole industry around proving that fat was bad for you developed but actually i mean this is really all about how you cut the data so this is a study that was done a few years later by your xiaomi and hilbo where they expanded 22 countries and you can see that the relationship is much less striking so the danger in doing this kind of research and then making policy recommendations off of it is if we're wrong it could have big implications for our health this is a picture of the food guide pyramid which was a u.s recommendation from the 1990s and you can see basically limit your fats you should eat the least amount of fats at the top of the pyramid there and eat the most amount of carbs and starches and rice and grains well if we're wrong about fat being bad for you which many people who eat a mediterranean diet would tell you like of course you should eat fat then we could actually be harming the population so nutrition research is flawed we do the best we can with the data and the resources that we have and all of this is pretty horrible from a public health perspective but what should be the role of government and policy makers here right i come from the us where our countrymen have a weaker stomach for government intervention than perhaps elsewhere so i want to approach this question from an economic perspective which means we want to think about markets and market failures so the ways in which our world may not be operating as nicely as it does in our economic models so traditionally when we talk about market failures we think of them in four flavors so we think about externalities the classic example being if i smoke and i produce secondhand smoke that harms your health that's a negative externality and represents kind of a traditional justification for the government to intervene over our behaviors market power is a little less difficult to justify in the context of obesity this would imply monopolies over foodstuffs and rising prices but in in fact we see the opposite issue we see falling food prices and falling food prices for items that are not incredibly healthy public goods is also a little bit difficult to justify in the realm of eating and food and maybe we could think about asymmetric information so this is the idea that companies or producers of the food have some information about the health of the food that the customers aren't privy to which opens up the policy options of informational campaigns and labeling right so one externality and i don't know if we want to call it an externality in the classic sense but one justification for intervention is that it's very expensive obesity and all of the comorbidities translate to have very high medical expenditures in the u.s case the u.s case we're looking at 147 billion dollars a year and that's a conservative estimate they go upwards depending on the study about half of this is borne by the public by the taxpayer in the form of our public health insurance programs the other half is represented in kind of what economists would call opportunity costs so this would be what we say absenteeism or presenteeism which means that individuals who weigh more are more likely to miss days of work and also less likely to be productive or as productive on the job so those are kind of the traditional ways that economists might think about why we would intervene in a market but there's another there's another assumption we make about free markets right which is that consumers are rational right and that we choose to be obese or that we choose to be overweight well is that true i mean how does this story change if we believe that there are addictive components to what we consume certainly larry would argue that for many individuals alcohol is incredibly addictive substance so to what extent do we want to think about helping people help themselves right a lot of that really depends on your view of addiction right the traditional view in economics is that we're all you know rational actors we solve these kind of constrained maximization problems in our head as we walk around the world but the problem with that is we never actually observe each other's maximization problems or utility functions and so we make assumptions that people behave in their own best interests right and there's a number of theories i won't get into the specifics about how we might make mistakes with respect to our consumption decisions right and all of this really matters this framing issue of who's to blame matters for creating support for public interventions this is a cartoon that kind of shows two different ways of of looking at the world right on the left the um the conservative or right wing view is like oh you know i have a problem this is my fault this is my choice and on the the liberal or the kind of progressive view is that uh oh the country has a problem so this is this represents a big challenge to effective policy right framing matters which explains the efforts by many public health advocates to prove the addictiveness of sugar or to frame the public as victims of the food environment to kind of search for a villain this is a graphic um it shows kind of mixed public support for these kind of policies in the u.s there was a a policy in new york city several years ago where the mayor banned the selling of large sodas and it was kind of universal backlash from from all parties against this this policy this is a sign on a back of a bus in new york city don't let them tell you what size to buy second challenge is that there's very little consensus on what's healthy as we've talked about and finally when we talk about regulating our eating behaviors we draw many of our lessons from our experience with other substances that we consider risky so tobacco alcohol and drugs there's many important differences between these substances right these represent single substances that are easy to regulate and easy to target there's very few substitutes for these substances and they're generally acknowledged as addictive with clear health risks so when we talk about food and how to regulate food what do we even need what are we regulating are we going to target sugar are we going to target soda are we going to target fat total calories i mean there's there's really very little consensus over what it is that makes us unhealthy and there are huge diet wars to this extent if you go to the the bookstore table in the in the plaza that they've set up for the conference there's a section where they're selling diet books and you can just look at the diet books and see that they're totally different one recommends vegan one recommends a mediterranean diet one says locale one says you need an ancestral paleo you know atkins diet what are you going to make of that if even the researchers don't know what's healthy for you how do we think about regulating food right and then the final problem or the final challenge with effective obesity policy is that the evidence on the effectiveness of any single policy is really dismal it turns out really the only thing that's effective in the long term at reducing weight at an individual level is bariatric surgery or gastric bypass and that's a very costly risky intervention okay okay so where does that leave us right where do we go from there what are some promising interventions i'm really going to skim over this i'll give a talk on sunday we'll talk more specifically about policies but if our concern is purely monetary right as economists we were concerned only about the financial burden to society of our obesity related expenditures then we want to look at strategies that are cost savings and that's a really high bar for publicly funded prevention programs to date there's no compelling evidence that obesity prevention programs save money it's not to say that there may not be a good reason to implement them just that cost savings may not be it the most effective or efficient strategy to recover the external costs of obesity would be to experience rate publicly funded health insurance programs and what i mean by that is charging individuals a differential for what they pay for insurance based on their health status and your your willingness to stomach or to agree with that kind of policy really depends on how you feel about you know whether or not you believe that people make rational decisions to eat and choose to be obese and then finally in the absence of experience rating governments are increasingly considering targeted sin taxes as a means to recoup their costs so these could be sugar sweetened beverage or soda taxes there was a fat tax i want to say i want to say belgium belgium or germany and even around these taxes there's very little consensus on what's appropriate or again what that targeted food item should be there's also very little evidence that they actually change consumer purchasing patterns let alone translate into clinically meaningful outcomes we could think about as a host of programs informational campaigns right so if we believe this is a problem of asymmetric information maybe what we want to do is try to educate the public about what they're eating that could be through menu labeling putting nutrition labels on products educating children in schools public service announcements this is everyone's favorite strategy because it imposes very little cost on everyone but people who don't want to use don't want to see the information don't have to the other problem is that they just don't generally work i shouldn't say that we don't see the effectiveness of any single informational campaign in any particular study i'm going to skip over this for now so what do we need you know we're clearly not there yet on this the nutrition science we need estimates of the relative importance of different behaviors so understanding whether it's calories whether it's eating whether it's exercising and what type of calorie we need evidence-based theories of behavior so understanding the extent to which addiction plays a role in our health outcomes and then of course we need effective interventions and i think developing effective intervention really depends on the getting the first two bullet points right thank you very much wait kirsten thank you thank you very much for this overview um maybe we can take some questions now yeah thank you for your talk um i have a couple of questions but but let's start with this one you said that there are no policies that are cost savings but i would say that most of our policies in any single health care sector are not cost saving so maybe if we set the bar about being cost effective then maybe we we can say yes we can promote those policies if we set the power of being co-saving then yes so i just wanted to specify it yeah okay any other con don't you want to say something no you're exactly right if we're trying to recoup costs we want to look at cost savings right so that would be the justification and that's a that's a really high bar as i mentioned because they're just not there across any health behaviors so cost-effective is the next best thing i was personally impressed by your presentation there's always the interdisciplinary approach that we should uh pursue and i believe that individual choices individual behaviors and the guidance that can be given by governments on individual behaviors should also be somewhat constrained so to what extent uh individual choices may be impacted by different factors not only knowledge because if i'm overweight for example i know perfectly well what i should eat and what i shouldn't eat but there are other factors that are at play as is true with other health problems so i was wondering if getting to know things and getting to know things also about emotional or framework situations may have an impact as far as obesity goes for example as with other health issues but in the case of obesity i believe that there is a stigma that goes with it that is perhaps obesity is perhaps of the condition that is accompanied by greatest stigma because they are obese or because they have wrong eating behaviors i don't think i don't know whether this can actually be of help i don't know whether communication wise that this kind of approach can be good or not i don't know whether there are any evidences on it sorry sorry i um i was wondering if the guilt appeal er in communication about obesity i mean uh to make people feel guilty for their behaviors uh is there any evidence about this about the effectiveness of this approach or not uh so i think we we see this kind of um the blame game with any kind of risky health behavior we saw it with tobacco too there's always this kind of tension between who's to blame right when in the case of smoking cigarettes you could make the case that you know we're all we all have free will and that we all can choose to smoke or not smoke but then there's kind of an entire um side of advocacy that seeks to kind of put the blame on the tobacco industry and say you know what you're doing and you're making us obese and we're kind of victims of this situation and sorry lung cancer and that that same tension exists when we talk about obesity and health related outcomes with respect to eating and that you have an entire camp who says if if you're fat it's because you're eating too much and shame on you and control yourself and i'm fine why can't you be fine and then we see we see the other side emerging as well which is um you know the system sets us up for failure if you walk into the pharmacy you have to walk through kind of an explosion of candy to even purchase your you know the products that are supposed to make you healthy if you drink a soda you have to drink five more because it's addictive and again how you frame that really matters for um engendering the public support for any particular policy that really goes beyond that kind of um neoclassical you know regulation okay thank you very much so now with uh so we've been talking about um our diet and the impact that the diet has on our health but we understand that the times are always we also uh in contradictions because for example young teenagers they never eat during the weekend and over the weekend that they drink a lot so the relationship with alcohol is also key this is something that we should consider as well studies that got published over the past few years showed that there's no minimum dose that is totally risk-free so when we look at mortality data also when we look at the onset of cancer we know that outcome hazard to play but we know that uh life our lives are risky we know that whatever choice we make is risky so when we sit at the table um we have to weigh risks and benefits when we drive our car we do likewise and also when we drink alcohol there are aspects that have to do with staying together and you know some little pleasure that goes with uh i mean having a nice lifestyle so that's all all these things have ought to be considered this is going to be the subject of professor koya's presentation he's an expert on the subject and he's going to present us the positive aspect of a balanced and healthy behavior when it comes to wine especially again with a special focus on wine if compared to other alcoholic drinks in trento uh one of the ways i learn a bit of italian is by watching italian television and one of the programs is un paso da sole i know so now i'm pretty close to being one step from heaven this is a great city you have here um my topic is wine and health and i will i'm going to have it in two parts so i'll stop in the middle for questions at that point if it's okay roberto so and i want to thank tito bury for asking for inviting me uh here that wine can be beneficial to mankind is is not a new concept it's been known to the ancients as being both healthful and actually have healing properties here we're going to examine the value of wine as as as part of our diet basically but also as part of a healthy lifestyle let's down here this is one of the key slides i wanted to indicate one of the misconceptions about wine is that it's often linked to alcohol to tobacco consumption and the mortality from alcohol versus cigarette smoking is very very different as you can see in these two graphs do we have a pointer well the graph on the left obviously shows the risk of all caused mortality as related to the number of cigarettes per day and one can see that even at the lowest levels of cigarette consumption the risk of 1.5 i have to define a drink is generally in the range of 14 to 15 grams of alcohol so with wine that's approximately 120cc glass of wine or u.s four ounce glass of wine on the right you can see the fact that on the right you can see the fact that the effects of alcohol are are twofold and as i could paraphrase paracelsus of a 16th century swiss physician any substance has poison in it it's all a matter of the dose and here you could see that at low levels alcohol can actually beneficial be beneficial with a 20 reduction in overall mortality at one drink per day it rises to back to a level of one a relative risk of one at three to four or even five drinks a day depending on the model that's being used and even at seven drinks a day in no way approaches uh that the effects of smoking uh cigarettes so tying alcohol consumption or linking alcohol and tobacco is is is an incorrect mis uh it is a misconception that i think we have particularly in the united states where the sale of alcohol is governed by an agency called the bureau of alcohol tobacco and firearms i'm very happy that pearson was able to point out that uh the literature that we have on diet and and wine consumption is not based on large randomized trials but rather aren't large observational trials usually uh retrospective uh trials um so here i i also want to point out that when one smokes uh cigarettes at one pack per day which some would consider late but it's actually the relative risk is three times uh that of non-smokers whereas a heavy drinker it's again only about a 1.2 or 20 percent higher uh relative risk so this is a very very important slide that type of a curve that you see for alcohol consumption where there's actually a benefit to low levels of alcohol consumption and the risk for higher levels of alcohol consumption oh thank you so this is where the benefit is this is called the j shape curve and the the high risk here uh for the higher levels of consumption have been reproduced this is a meta-analysis of over two no actually over one million uh participants in over 36 studies one of the other misconceptions uh that has led to the demonization of alcohol at least in the united states is the temperance movement which actually started not long after the american revolution and at that time there was a problem in the united states with mostly with heavy spirit drinking and the temperance movement was started to moderate alcohol consumption but that moderation over the next century became one of not just moderation but the need for total abstinence and a real demonization of alcohol this is a print a courier an ice print from 1919 which depicts people who are interested in having beer wine whiskey etc entering a saloon and going on the road to ruin so in 1919 enacted in 1920 was the 18th amendment to the u.s constitution which prohibited the sale of alcohol and that lasted until 1933 to borrow a term from alvin roth this was a repugnant i'm sorry repugnant uh market uh for many but it really was not that uh repugnant because the black market that existed because so many people wanted to drink alcohol actually led to a lot of problems subsequently with a big use of criminal uh sales in the black market and the that criminality persisted even after the alcohol sales were over because they moved into other industries so i've already mentioned in that second slide the importance of moderation one or two drinks of alcohol has beneficial effects but you can't average one or two drinks per day over a week and say well i'm going to drink all my seven drinks on saturday you cannot bring binge drink there are several studies that show that late to moderate drinkers who occasionally drink heavily have significantly higher mortality than those who do not drink heavily now why is alcohol important or how is alcohol reducing mortality it's mostly through a reduction in cardiovascular risk and you saw in kirsten's slide how important cardiovascular risk in in the united states and in other countries it's one of the leading causes of of death well the risk of fatal and non-fatal cardiovascular events are reduced by nearly 30 percent with moderate alcohol consumption mainly mi or myocardial infarction and stroke are reduced even as far as cardiovascular disease fatal ventricular arrhythmias that would be sudden death uh is decreased with one drink per day but binge drinking on the other hand uh generally defined as four to six strengths on at at least uh one occasion per month or more frequently is associated with an increased risk of non-fatal atrial arrhythmias how does the alcohol affect the cardiovascular system and and would i say for alcohol i'm using because there is more research on alcohol than on wine there are larger studies but i will give you some other evidence that this applies to wine in fact if anything wine uh has probably more beneficial effects than just alcohol in general alcohol and some of the effect of polyphenols in wine will can increase high density lipoprotein that's the good cholesterol it can improve flow and clotting properties of blood it basically it decreases platelet adherence decreases production of fibrinogen it promotes fibrinolysis lowers stress and inflammation if you look at certain markers in the bloodstream for inflammation they are significantly lower with moderate alcohol consumption relaxes a blood vessel so that even patients with hypertension who drink moderately can see some reduction in in blood pressure over time i found this interesting that studies with over 400 000 patients suggest that a moderate alcohol consumption can reduce the incidence of type 2 diabetes and that those with type 2 diabetes can benefit modestly but can benefit from low levels of alcohol consumption interesting study a nurse's health study in the united states with over 12 000 participants indicated that uh there's a significant risk uh risk reduction uh in mental abilities with age so that nurses who were 73 years old were performing on mental ability tests as if they were 71 years old so a couple year improvement in mental abilities with moderate to light drinking of alcohol also reduced risk for dementia and alzheimer's has been more recently shown in in large meta-analyses but also can have benefits like inhibiting production of gallstones and kidney stones but this is what we are faced with as physicians and and population understand uh that alcohol use can be very harmful to health but in general we're talking about heavy alcohol consumption i i can tell you that in the united states every bottle of wine or alcohol has to have three statements on it from the us surgeon general the first is that alcohol can cause intoxication and it is a major contributor to automobile accidents alcohol can cause birth defects in fact the fetus and cause birth defects so it's not recommended for pregnant women to have it and the surgeon general also says that it may a harm be harmful to your health it says nothing about being beneficial so all these things are aren't our labels in the united states with alcohol consumption we know it can cause problems with the liver hepatic dysfunction with cirrhosis and interference mata with metabolism my specialty was radiation oncology so i treated many cancers of different types and i'm quite familiar with those that can be caused by alcohol consumption at heavy levels and particularly those of the upper air digestive tract and liver that would be the oral cavity the uropharynx hypopharynx larynx now there has been a recent study or meta-analysis i should say that addresses uh more moderate consumption and its increase in the risk of breast cancer of approximately seven percent five percent in pre-menopausal is nine percent of postmenopausal women and i could uh talk about that uh more if the audience wishes uh later other significant effects although low levels might in fact help the hypertensive patient uh it is linked to hypertension at more than three or equal to three drinks per day as i mentioned earlier can cause atrial arrhythmias that were uh six drinks a day will double the risk uh the risk for hemorrhagic stroke increases the hemorrhagic stroke is about 15 of all strokes uh but that is uh significant uh immune super uh suppression uh can be induced so the patients who are immune suppressed or receiving chemotherapy uh generally have to drink alcohol in a very very moderate amounts and of course it can cause pancreatitis gastritis to uhnitis or inflammation of many structures now to switch the topic specifically more specifically to wine this study that was reported from denmark in 1995 so over 20 years ago was one of the first to suggest that alcohol is not the same so beer is not the same as wine which is not the same as spirits in terms of health risks and here the study uh which was a large over 13 000 people for studied for a long period of time was controlled for exercise social standing education and income level uh showed a sixty percent lower risk of heart attack fifty percent risk of overall mortality uh than abstinence the equivalent amount of beer at least in this study had no impact on mortality and the equivalent amount of spirits increased mortality uh 20 percent now uh this study was criticized because it was found that there were some co-founding factors that weren't uh uh controlled for as kirsten said there are other factors that need to be and and many of the patients who preferred wine also preferred a more healthy diet in terms of more fruits and vegetables etc however a recent meta-analysis did indicate that uh and i think it included over 100 000 people in the various studies uh did indicate this j shaped curve that you saw for alcohol in general specifically applies to wine and to beer but could not be reproduced for spirits and i might have some reasons for that later on if we wanted to go into it so how much of alcohol is consumed as wine versus others well it really depends on where you're at it's only eight percent of alcohol consumption worldwide it's much more in europe but 25 percent in fact in italy it's two-thirds of the alcohol consumed is is wine and in the americas it's about 12 percent in the u.s in particular it's 17 i'm going to close this first part and and open to set uh questions if it's okay with roberta to say uh you know i'm probably in the wrong place to talk about wine and health because alkens i think the italians already appreciate the value of a mediterranean diet and adding wine to that diet it was recently ranked as number one in the world by the bloomberg healthiest country index and uh second in the world in the healthcare systems by the world health organization so congratulations thank you very much larry for your italian too italian you can ask them now then there is a second part of the presentation but so we can be interactive in english or in italian and italian otherwise i like you yes i have a question when you talk about wine do you mean white or red wine no no nothing to laugh in in the next part of my talk i'll look at the red wine versus white wine in general the studies in vivo in people don't show a significant difference but the laboratory studies would suggest that the antioxidant activity the use the amount of polyphenols in red wine is 6 to 12 times higher in red wine than white and the potential for decrease in cardiovascular risk through the factors that i mentioned earlier decreasing high-density lipoprotein etc are much much better for red wine than for white but again we don't have supports in humans to say that's absolutely the case as kirsten said earlier there's a big gap between you know what we think is right in theory and in the lab and what is really happening in in humans because of all the other factors so as kirsten explained to us before it is very difficult to carry out this kind of studies and it is easy to confound an occasional relationship or correlation with a cause effect link i do not know whether we are the healthiest country in the world thanks to wine um i'm a bit doubtful about that in italy today young people have taken on the bad habit of drinking wine and long drinks where you have some and they keep drinking that because they do not perceive the alcohol content i think this can be very dangerous this is a good point and it actually connects to two presentations did you hear the presentation it is a real problem in fact if you look at the consumption of wine in italy it has been decreasing over the last few decades and as the uh person pointed out many of the are changing to spirits and drinks which are higher in sugar and these are not beneficial to health as alcohol as a wine can be so i think italians must remember if they're going to continue a guide in salute to drink wine in moderation and not substitute it with sugary high spirit drinks and i believe that the sugar the sugar intake through drinks with or without alcohol doesn't give you the idea that you are eating sugars i mean if you eat a big cake you know that you're having something sweet with sugar but drinking something you do not perceive that is that right is that working yeah if you think about the ways that you would get sugar in nature it usually comes packed with fiber so if you think about fruit which is very sweet the sweetest fruits so you could think about sugar cane in its purest form you'd have to gnaw through wood to get to that sugar that's pure fiber and it kind of is this nice correlation between sugar and the amount of peel that you have to get through so apples which aren't as sweet don't have as much fiber watermelons which are very sweet you have to get that fiber so when you eat it in a more natural form it usually comes with compounds that help protect your your body the other thing i'll mention is that obesity rates in the middle east are actually quite high and one of the hypotheses for that those rising rates are that those countries they don't drink alcohol and so the the form of socialization is to drink a lot of soda or drink a lot of fruit juice and so you're getting a lot of pure sugar that's spiking insulin the insulin storing those calories and the blood sugar is fat and you know it's a perfect storm okay would you like to go on with your presentation any other questions we can also continue with the questions afterwards keep in mind when i speak about recommendations i i am a physician but i'm not your doctor and i think it's fundamental to everyone to know that they need to can take take control of their lives themselves and that's why you're here to to learn what's best i've already mentioned what is in a drink of alcohol it's about the term one drink has been formalized but not a hundred percent throughout all countries but it's generally four or five ounces a dry wine would have half percent sugar or less generally 11 to 14 alcohol and about 100 to 120 calories doesn't have much in the way of other nutrients a little vitamins b and c and some some elements but what it does has as was brought out earlier uh are the polyphenols resveratrol is a still bean there are anthocyanins the color of the wine particularly red and so they're much greater in red wine than white but beer also has polyphenols just a bit less and that might be one of the reasons that it takes a little bit more beer to reach the neater and and go back to a relative risk of one because the you need more of those polyphenols than are available in one liter or a half a liter of bureau so does wine have something special that other alcoholic beverages does not it's probably the the polyphenols in addition to the alcohol these substances are found in fresh fruits and vegetables but are in a greater concentration in red wine and you know one of the things that contributes to our aging and problems are free radical formation or oxidation as a radiation oncologist i caused that by radiation unfortunately it killed the tumor more than aging the other tissue but these free radicals that are formed by cigarette smoking or stress or inflammation can be harmful to the health and having an antioxidant which would then take those uh electrons from the free radicals and bind them that's what antioxidant activity is can be helpful to health and you find a lot of it in tea and apples beer apple juice but in general as i said earlier it is in higher in red wine than others but this is just part of what i think is a healthy lifestyle it's not just drinking wine or controlling weight it's exercising regularly i suggest when i have patients i'm retired now but that each person should work up a sweat at least a couple times a week that usually means that they've burnt enough calories uh obviously don't smoke cigarettes i hope you saw in that second slide how detrimental even one to four cigarettes is try to reduce stress relax control root weight the italians have been very good at that but it sounds like the younger generation might be having some problems and have the healthy diet which includes a wine with meals i'm not really going to go into that in detail uh these things do change but this is one of the present recommendations actually from harvard but you see they also have a little thing here says mulvaty and so it's not just a diet exercise and another one from harvard the first dietary pyramid that i saw that actually included wine is this one from harvard and it's a healthy eating pyramid and says optional alcohol in moderation not for everyone one of the things uh that's stated and and i should mention some of the best literature if you want to read more about consumption of wine and moderation read the literature from italy from your food and nutrition center and from uh there's a study there's a catolica universita in campobasso that's doing some great research so i think the italians are leading the world in in some of the wine and moderation research that's where i got a lot of my information anyway so um now this is not my recommendation this is i just wanted to show you this is anstey's rule in 1870 recognizing that the standard recommendation is one to three drinks maximum per day and can be varied on the individual hypertension two or less a day diabetes dry wine at one a day females one drink a day liver problems consult your doctor heavy drinkers cut back to one or two uh they were abstaining so those were my concluding slides i don't really have any more some people ask me well you know if you promote low levels of alcohol some some people are going to become alcoholics and alcoholism obviously is a big problem and and think drinking is as well i there i could not find the data to suggest how many people who are alcoholic to drink wine only it wasn't available for me so i just did a rough estimate of rates of alcoholism actually are quite high in the u.s compared to italy one half percent in italy almost five percent in the united states percent wine consumers though in italy is is two-thirds of the population as i mentioned earlier so this is not correct but it may give you an estimate that maybe a third of a percent would be alcoholic wine consumers just to get an idea of if you're going to recommend something you know what what are the long-term detrimental effects and the economic effects of it thank you i think it has to do with culture as well because wine is usually consumed in moderate doses whereas alcoholic drinks are usually drunk in binge drinking or in large quantities anyway because exaggerating with uh alcoholic drink is kind of easier more questions i'm in italy but this in the 1990s this the fact that the french could eat diets high in fat and yet had very low risk of cardiovascular disease it was called the french paradise why could this happen and i thought part i'll just repeat that again uh i didn't use the term uh french here because i'm in italy but in the 1990s there was a revelation that the french could eat diets which were high in fat and but yet had a very low risk of cardiovascular disease and and why was that and uh this was termed as the french paradox but in fact uh over the years one can see that the french diet of high in fats is also cheese and some of those fats are bound uh they consume it rather leisurely with a meal and not in a you know in a high alcohol drink so these are other factors that need to be considered i have a question we know of a correlation the correlation exists in between two drinks a day and drugs i believe that uh after 50 when you turn 50 you would start taking pills drugs so what is the effect of the combined uh intake of pharmaceutical products and wine you know first physicians are told do not tell one people who your patients who are abstaining to drink alcohol for health reasons and i can understand that because the potential becoming alcoholic etc but another reason is many times they can't drink alcohol because it does change the efficacy of some of the drugs that they might be taking and one has to be very careful about that on the other hand there is no more effective drug than alcohol in reducing cardiovascular mortality if you were to choose one single truck it would it would be alcohol i've got another physician who disagrees but that's fine that's wrong we all can do some cherry picking and uh evidence tutor well we tend always to present uh the um studies the trials that we like best so we can find all kind of information so i'm glad to learn that that glass of prosecco doesn't hurt me but i believe that we should all refer to our physicians for specific recommendations considering the drugs that we are on more questions from the floor reference was made to the optimal dosage of two cups a day to uh is this exactly the same for women or isn't the half but isn't the hat for women where there's a benefit it does have its nader for both men and women at about one drink per day but for men they're still less likely to do harm if you go to two drinks per day however if women were to drink two day drinks per day that would be more harmful the reasons for that are not known there's two speculations one is that the alcohol dehydrogenase in women is generally lower than men so the alcohol stays around longer the other is uh that women have a higher percentage of body fat when alcohol binds to the body fat and can stay around longer so these are two potential explanations but yes there are differences in metabolism and difference in recommendations for the men and women another point is the the size of glasses well this morning i was reading scaffolder who's the top expertly on alcohol stating that over the years open glasses have are becoming ever larger so when we say one glass a day we should consider half class a day 125 ml so we shouldn't actually fill up a glass as they think that this is just one drink because usually a full up glass which is completely filled is perhaps two glasses five ccs okay in the first slide you showed us so that if you drink over if you smoke over a pack a day you have a reduction in death rate with women with over a pack uh death but now the question is i was surprised as well because in the graph mortality seems to decline i i did see i'm so that yes when you drink uh smoking one pack of cigarettes a day there was some decline in was it for women or men for women but i think it was a mistake i don't know i don't know the reason for that no i don't think so it was still too high quick a question on the use of preservatives for wine sulfites and others the problem with sulfites uh at high again it's as paracels it's all every substance has its poison it's all a matter of dose at the high levels it could be harmful at low levels it might not do anything or it might even be helpful i don't know if kirsten you have any uh comments about sulfites you know i can tell you that organic growers can use sulfites in their in their wine making process now i don't know if they could be if there's a special label in italy that doesn't allow sulfites for or organic growers or not but in the us they can use sulfites i wouldn't know maybe somebody is more learned than i am do we have more questions maybe a question for kirsten on the role of policies of governmental policies in attacking the problems connecting with child obesity very interesting initiatives have been launched by michelle obama to tackle the problem of children obesity in the us did it lead to any change or a lot of advertising and propaganda perhaps no effect so michelle obama had a lot of initiatives around getting children to move more so physical activity and i think one thing that a lot of people will agree on is that when we think about the relative importance of nutrition and physical activity for weight loss and for health nutrition plays a bigger role than physical activity does that mean people will tell you it's 80 20. and i my personal belief is that she she focused on physical activity because it's um it was politically easier you know there's a lot of food lobbies and a lot of vested interests in the u.s from the beverage associations from sugar lobbyists from a variety of food companies and you know policy initiatives around changing what children eat in schools are very controversial and so physical activity was kind of an easy target but not necessarily the area in which we'd expect to see a lot of change okay thank you very much any other comment or questions i think i can call you today would like to thank our guests and like to thank also all of you for staying with us thank you you